Annals of Indian Academy of Neurology
  Users Online: 2669 Home | About the Journal | InstructionsCurrent Issue | Back IssuesLogin      Print this page Email this page  Small font size Default font size Increase font size

Table of Contents
CASE REPORTS
Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 103-106
 

Glioblastoma multiforme associated with arteriovenous malformation: A case report and literature review


1 Department of Surgery, Division of Neurosurgery, Prince of Songkla University, Songkhla, Thailand
2 Department of Pathology, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkhla, Thailand

Date of Web Publication21-Jan-2020

Correspondence Address:
Dr. Thara Tunthanathip
Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla 90110
Thailand
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.AIAN_219_18

Rights and Permissions

 

   Abstract 


Although microvascular proliferation can be observed in glioblastoma, obvious vascularity coupled with coexisting cerebral arteriovenous malformation (AVM) is extremely rare. This report is of a rare case of glioblastoma, coexisting with a cerebral AVM. A 20-year-old male presented with progressive right hemiparesis within 1 month. Cranial magnetic resonance imaging revealed a large bleeding tumor with surrounding dilated vessels. Cerebral angiography demonstrated a left frontal AVM with a 1.2 cm nidus. The patient underwent preoperative embolization and radical resection. The coincidence of glioma and AVM was a rare association. However, the concept of hypervascular glioblastoma has been used in different states from different literature reviews; therefore, the role of proangiogenic factors should be addressed


Keywords: Angioglioma, arteriovenous malformation, glioblastoma, hypervascular glioblastoma


How to cite this article:
Tunthanathip T, Kanjanapradit K. Glioblastoma multiforme associated with arteriovenous malformation: A case report and literature review. Ann Indian Acad Neurol 2020;23:103-6

How to cite this URL:
Tunthanathip T, Kanjanapradit K. Glioblastoma multiforme associated with arteriovenous malformation: A case report and literature review. Ann Indian Acad Neurol [serial online] 2020 [cited 2020 Feb 24];23:103-6. Available from: http://www.annalsofian.org/text.asp?2020/23/1/103/249709





   Introduction Top


Glioblastoma multiforme (GBM) is the most common malignant primary brain tumors in adults. Although microvascular endothelial proliferation is one of the criteria for a histological diagnosis, grossly hypervascular glioblastoma is an unusual manifestation. The authors described a patient, who suffered from a combination between glioblastoma and cerebral arteriovenous malformation (AVM). This case also highlights the rare angiomatous manifestation of glioblastoma.


   Case Report Top


A 20-year-old male developed progressive right hemiparesis on the right side within 1 month. Cranial magnetic resonance imaging (MRI) scans demonstrated a heterogeneously enhancing mass, 5.5 cm × 8 cm in size, with internal hemorrhage at the left frontal lobe. In addition, surrounding dilated arteries and veins at the adjacent cortex were noted on T1-weighted with gadolinium. On cranial computed tomography, the dense calcification located an inferior portion of the mass. Cranial magnetic resonance angiography revealed dilated peripheral branches of the anterior cerebral artery and middle cerebral artery (MCA) with dilated cortical veins [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d.
Figure 1: Preoperative neuroimaging. (a) T1-weighted coronal (b) and T1-weighted axial images with gadolinium administration demonstrated a large left frontal mass with flow void signs. (c) Cranial computed tomography revealed calcification at the inferior portion of the mass. (d) Cranial magnetic resonance angiography revealed multiple dilated vessels surrounding the tumor

Click here to view


Moreover, a cerebral angiographic study revealed a nidus, approximately 1.2 cm wide in the subcortical region of the left precentral sulcus. This was fed from the distal branches of the left precentral artery and anterior parietal artery of the left MCA. The flow drained into a single cortical vein to the superior sagittal sinus [Figure 2]a and [Figure 2]b.
Figure 2: Preoperative cerebral angiography. (a) Anterior-posterior view and (b) lateral view showed a nidus in the subcortical region of the left frontal lobe. It was supplied by distal branches of the left precentral artery and anterior parietal artery of the left middle cerebral artery. The venous drainage was to the cortical vein to the superior sagittal sinus

Click here to view


A preoperative embolization was performed for reducing blood loss during surgery before a craniotomy. Intraoperative findings revealed a well-defined, reddish tumor with obvious abnormal vessels occupying both superficial and deep portions of the tumor. Interestingly, the hypervascular tumor was toughly attached with dura. The tumor was completely removed.

Pathologic examination

Gross characteristics of the tumor were extra-axial mass, reddish-gray color, dural attachment, firm-solid consistency, and fed from multiple dilated arteries. In addition, calcification was observed at the inferior portion of the tumor. Therefore, the gross features mimic meningioma [Figure 3]a, [Figure 3]b, [Figure 3]c.
Figure 3: Gross appearance of the tumor. (a) Extra-axial mass was observed in the operative field. (b) The superior aspect of the tumor could be observed, the tumor attached dura matter (white arrow), and multiple feeding arteries (black arrow) were around the tumor. (c) The inferior aspect of the tumor could be observed, dense calcification (white arrow)

Click here to view


A histopathological examination demonstrated nuclear polymorphism astrocytes and necrosis without sarcomatous spindle morphology. Therefore, gliosarcoma was excluded. The tumor was composed of numerous enlarged blood vessels of varying sizes, and dural morphology was normal. Finally, the diagnosis was glioblastoma associated with AVM [Figure 4]a, [Figure 4]b, [Figure 4]c, [Figure 4]d.
Figure 4: Histological examination of the tumor. (a) Tumor attached normal dura matter and numerous blood vessels in varying sizes were within the tumor. (b) The necrotic area was observed. (c) The neoplastic glial cells had nuclear enlargement with hyperchromatic nuclei, and irregular nuclear membrane and mitotic activity could be observed (black arrow). (d) Immunoreactivity of the tumor was positive for GFAP

Click here to view


After tumor resection, the patient received postoperative adjuvant radiation. Six months after the first operation, the patient presented with alteration of consciousness and tumor recurrence was observed by neuroimaging. Due to these factors, he then underwent the second operation. Postoperatively, his consciousness improved, but tumor regrowth occurred, again, 1 year later, after the second operation. His family refused the third operation, and subsequently, he died in 2 years after the first operation.


   Discussion Top


Glioblastoma is an aggressive primary brain tumor that has composites of necrosis and microscopic endothelial proliferation.[1] The term “angioglioma” had been used in glioma associated with various vascular abnormalities; however, this term was primarily defined by Russell and Rubinstein, who described angioglioma from patients with the cystic cerebellar tumors with coexisting glioma and hemangioblastoma.[2] Hence, the authors reviewed literature using the keywords such as “angioglioma,” “glioblastoma AND arteriovenous malformation,” “hypervascular glioma,” “glioma AND arteriovenous malformation,” and “vascular malformation AND glioma.” We excluded “angiocentric glioma,” because this entity is a distinct group of epileptogenic tumors, according to the 2016 WHO classification of tumors of the central nervous system. As a result, the cases are summarized in Supplementary [Table 1]. Histopathology of angiocentric glioma demonstrated spindled cells forming occasionally perivascular pseudorosettes.[3][Additional file 1]

Form the literature review, the coexistence of glioma and vascular malformation is a rare entity. To the best of the authors' knowledge, at least 67 cases have been described before this present case. From [Table 1], hypervascular gliomas are common in males (55.9%) and the distribution of age is between 2 and 72 years (mean age was 35 years).[2],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31] In vascular malformation, AVM is the common coexisting vascular malformation. Using cerebral angiography, high blood flow passes through the arteriovenous shunt.[4],[5],[9],[10],[11],[16],[17],[18],[19],[21],[22],[23],[24],[25],[26],[27],[30] In addition, various tumors have been reported as having the coexistence of glial cell tumors as well as other various tumors, either vascular tumor (cavernous, capillary hemangioma)[6],[8],[12],[14],[15],[20] or other hypervascular tumors (hemangioblastoma).[2],[7],[32]

These coexistences have been found in both low-grade and high-grade gliomas. The common glial cell tumors are GBM, pilocytic astrocytoma, and oligodendroglioma. In histological features, GBMs usually found endothelial cell proliferation and glomeruloid appearance while pilocytic astrocytoma and oligodendroglioma found other characteristics of abnormal vessel pattern. Hyalinized and glomeruloid vessels could be prominent features in pilocytic astrocytoma whereas oligodendroglioma typically shows a dense network of branching capillaries resembling the pattern of chicken wire.[1] However, the overexpression of proteins of tumor angiogenesis pathway is proposed in the hypothesis of the pathophysiology of this coexistence.

Upregulation of angiogenetic-driven events has been hypothesized that induced abnormal vasculatures in hypervascular glioma.[33] C-X-C chemokine receptor type 4 (CXCR4) is a chemokine receptor for C-X-C motif chemokine ligand 12 (CXCL12) that is associated with angiogenesis and tumor progression. The receptors are upregulated by hypoxia-inducible factor-1 (HIF-1) and vascular endothelial growth factors (VEGFs). Reactivity of the HIF-1α subunit and VEGF was highly expressed in pseudopalisading tumor cells adjacent to necrosis. However, a high VEGF expression and overexpression of CXCL12-CXCR4 axis were observed in angiogenic vessels.[23],[34]

In vascular malformation, it has been shown that VEGF expression is a fundamental part of intracerebral AVM pathogenesis. VEGF levels are increased in intracerebral AVM.[35] Upcoming molecular research should be studied to demonstrate the common angiogenetic-driven mechanisms between coexisting lesions. As the results, hypervascular glioma is the presence of dark vessel-like signals (flow void signs) on T2-weighted imaging located within the tumor. These represented the prominent serpiginous vessels.[21] Moreover, the histopathologic characteristics reveal clusters of numerous blood vessels of various size.[14]

As for the treatment strategy, radical resection is the treatment of choice in hypervascular glioma, but these tumors are challenging for total tumor resection. Unfortunately, significant intratumoral hemorrhage frequently occurs in this tumor. Emergency decompressive craniectomy with/without lesionectomy should be performed for saving of life. However, the risk of enormous bleeding during surgery has to be considered. Hence, in elective conditions, preoperative endovascular embolization is an alternative method for reducing blood loss, when the tumor is resected. Imai et al. proposed preoperative embolization as a strategy that tumors which located in eloquent areas need provocation testing beforehand. Presurgical embolization for tumor feeder vessels is recommended in negative provocation testing.[27]


   Conclusions Top


We described a rare manifestation of GBM. Proangiogenic factors are most likely involved in the existence of both entities at the same location. Future molecular studies may reveal a common genetic pathway to explain this association. Surgical treatment is challenging due to the risk of massive intraoperative bleeding. Preoperative endovascular embolizations are alternative methods for controlling intraoperative blood loss.

What is already known on this topic?

GBM is the most common primary malignancy of the brain in adults. One of the histological characteristics involves microvascular proliferation such as endothelial proliferation and glomeruloid appearance.

What does this study add?

This case report demonstrated the rare coexistence between GBM and cerebral AVM. The hypothesis of pathophysiology is overexpression of proteins of tumor angiogenesis pathway.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Louis DN, Brat DJ, Ohgaki H, Stupp R, Suva ML, Biernat W, et al. Glioblastoma, IDH-wildtype. In: Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, editors. World Health Organization Classifi cation of tumours of the Central Nervous System. Revised 4th ed. Lyon: The International Agency for Research on Cancer; 2016. p. 28-45.  Back to cited text no. 1
    
2.
Russell DS, Rubinstein LJ, editors. Pathology of Tumours of the Nervous System. 5th ed. London: Edward Arnold; 1989.  Back to cited text no. 2
    
3.
Burger PC, Jouvet A, Preusser M, Rosenblum MK, Ellison DW. Angiocentric glioma. In: Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, editors. World Health Organization Classifi cation of Tumours of the Central Nervous System. Revised 4th ed. Lyon: The International Agency for Research on Cancer; 2016. p. 119-20.  Back to cited text no. 3
    
4.
Zuccarello M, Giordano R, Scanarini M, Mingrino S. Malignant astrocytoma associated with arteriovenous malformation. Case report. Acta Neurochir (Wien) 1979;50:305-9.  Back to cited text no. 4
    
5.
Foy PM, Lozada L, Shaw MD. Vascular malformation simulating a glioma on computerized tomography. Case report. J Neurosurg 1981;54:125-7.  Back to cited text no. 5
    
6.
Fischer EG, Sotrel A, Welch K. Cerebral hemangioma with glial neoplasia (angioglioma?). Report of two cases. J Neurosurg 1982;56:430-4.  Back to cited text no. 6
    
7.
Bonnin JM, Peña CE, Rubinstein LJ. Mixed capillary hemangioblastoma and glioma. A redefinition of the “angioglioma”. J Neuropathol Exp Neurol 1983;42:504-16.  Back to cited text no. 7
    
8.
Chee CP, Johnston R, Doyle D, Macpherson P. Oligodendroglioma and cerebral cavernous angioma. Case report. J Neurosurg 1985;62:145-7.  Back to cited text no. 8
    
9.
Licata C, Pasqualin A, Freschini A, Barone G, Da Pian R. Management of associated primary cerebral neoplasms and vascular malformations: 2. Intracranial arterio-venous malformations. Acta Neurochir (Wien) 1986;83:38-46.  Back to cited text no. 9
    
10.
Goodkin R, Zaias B, Michelsen WJ. Arteriovenous malformation and glioma: Coexistent or sequential? Case report. J Neurosurg 1990;72:798-805.  Back to cited text no. 10
    
11.
Lombardi D, Scheithauer BW, Piepgras D, Meyer FB, Forbes GS. “Angioglioma” and the arteriovenous malformation-glioma association. J Neurosurg 1991;75:589-66.  Back to cited text no. 11
    
12.
Hasegawa H, Bitoh S, Koshino K, Obashi J, Kobayashi Y, Kobayashi M, et al. Mixed cavernous angioma and glioma (angioglioma) in the hypothalamus – Case report. Neurol Med Chir (Tokyo) 1995;35:238-42.  Back to cited text no. 12
    
13.
Lee TT, Landy HJ, Bruce JH. Arteriovenous malformation associated with pleomorphic xanthoastrocytoma. Acta Neurochir (Wien) 1996;138:590-1.  Back to cited text no. 13
    
14.
Kasantikul V, Shuangshoti S, Panichabhongse V, Netsky MG. Combined angioma and glioma (angioglioma). J Surg Oncol 1996;62:15-21.  Back to cited text no. 14
    
15.
Tews DS, Bohl JE, Van Lindert E, Ringel K. Association of oligodendroglioma-like cell proliferation and angiomatous vasculature – Coincidence or pathogenetically related lesions? Clin Neuropathol 1998;17:69-72.  Back to cited text no. 15
    
16.
Harris OA, Chang SD, Harris BT, Adler JR. Acquired cerebral arteriovenous malformation induced by an anaplastic astrocytoma: An interesting case. Neurol Res 2000;22:473-7.  Back to cited text no. 16
    
17.
Ziyal IM, Ece K, Bilginer B, Tezel GG, Ozcan OE. A glioma with an arteriovenous malformation: An association or a different entity? Acta Neurochir (Wien) 2004;146:83-6.  Back to cited text no. 17
    
18.
Cemil B, Tun K, Polat O, Ozen O, Kaptanoglu E. Glioblastoma multiforme mimicking arteriovenous malformation. Turk Neurosurg 2009;19:433-6.  Back to cited text no. 18
    
19.
Pallud J, Belaid H, Guillevin R, Vallee JN, Capelle L. Management of associated glioma and arteriovenous malformation – the priority is the glioma. Br J Neurosurg 2009;23:197-8.  Back to cited text no. 19
    
20.
Gazzeri R, De Bonis C, Carotenuto V, Catapano D, d'Angelo V, Galarza M, et al. Association between cavernous angioma and cerebral glioma. Report of two cases and literature review of so-called angiogliomas. Neurocirugia (Astur) 2011;22:562-6.  Back to cited text no. 20
    
21.
Aucourt J, Jissendi P, Kerdraon O, Baroncini M. Neuroimaging features and pathology of mixed glioblastoma – AVM complex: A case report. J Neuroradiol 2012;39:258-62.  Back to cited text no. 21
    
22.
Soltanolkotabi M, Schoeneman SE, Dipatri AJ, Hurley MC, Ansari SA, Rajaram V, et al. Juvenile pilocytic astrocytoma in association with arteriovenous malformation. Interv Neuroradiol 2012;18:140-7.  Back to cited text no. 22
    
23.
Gmeiner M, Sonnberger M, Wurm G, Weis S. Glioblastoma with the appearance of arteriovenous malformation: Pitfalls in diagnosis. Clin Neurol Neurosurg 2013;115:501-6.  Back to cited text no. 23
    
24.
Khanna A, Venteicher AS, Walcott BP, Kahle KT, Mordes DA, William CM, et al. Glioblastoma mimicking an arteriovenous malformation. Front Neurol 2013;4:144.  Back to cited text no. 24
    
25.
Nagańska E, Matyja E, Pucko E, Ząbek M. The coexistence of pleomorphic xanthoastrocytoma and arteriovenous malformation. A case report. Folia Neuropathol 2013;51:269-74.  Back to cited text no. 25
    
26.
Boikov AS, Schweitzer AD, Young RJ, Lavi E, Tsiouris AJ, Gupta A, et al. Glioblastoma-arteriovenous fistula complex: Imaging characteristics and treatment considerations. Clin Imaging 2014;38:187-90.  Back to cited text no. 26
    
27.
Imai T, Ohshima T, Nishizawa T, Shimato S, Kato K. Successful preoperative endovascular embolization of an extreme hypervascular glioblastoma mimicking an arteriovenous malformation. World Neurosurg 2016;86:512.e1-4.  Back to cited text no. 27
    
28.
Li WQ, Wang X, Zhong NZ, Li YM. Spinal hemangioblastoma combined with pilocytic astrocytoma. Neurosciences (Riyadh) 2015;20:280-4.  Back to cited text no. 28
    
29.
Linsenmann T, Westermaier T, Vince GH, Monoranu CM, Löhr M, Ernestus RI, et al. Primary spinal glioblastoma multiforme with secondary manifestation as a cerebral “Angioglioma.” literature review and case report. J Neurol Surg Rep 2015;76:e128-34.  Back to cited text no. 29
    
30.
Lohkamp LN, Strong C, Rojas R, Anderson M, Laviv Y, Kasper EM, et al. Hypervascular glioblastoma multiforme or arteriovenous malformation associated glioma? A diagnostic and therapeutic challenge: A case report. Surg Neurol Int 2016;7:S883-8.  Back to cited text no. 30
    
31.
Joshi KC, Khanapure K, Hegde N, Ravindra N, Jagannatha AT, Hegde AS, et al. Angioglioma of the spinal cord. World Neurosurg 2016;96:610.e5-000.  Back to cited text no. 31
    
32.
Matyja E, Grajkowska W, Taraszewska A, Marchel A, Bojarski P, Nauman P. Advanced reactive astrogliosis associated with hemangioblastoma versus astroglial-vascular neoplasm (“angioglioma”). Folia Neuropathol 2007;45:120-5.  Back to cited text no. 32
    
33.
Huang WJ, Chen WW, Zhang X. Glioblastoma multiforme: Effect of hypoxia and hypoxia inducible factors on therapeutic approaches. Oncol Lett 2016;12:2283-8.  Back to cited text no. 33
    
34.
Zagzag D, Lukyanov Y, Lan L, Ali MA, Esencay M, Mendez O, et al. Hypoxia-inducible factor 1 and VEGF upregulate CXCR4 in glioblastoma: Implications for angiogenesis and glioma cell invasion. Lab Invest 2006;86:1221-32.  Back to cited text no. 34
    
35.
Walker EJ, Su H, Shen F, Degos V, Amend G, Jun K, et al. Bevacizumab attenuates VEGF-induced angiogenesis and vascular malformations in the adult mouse brain. Stroke 2012;43:1925-30.  Back to cited text no. 35
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
Print this article  Email this article

    

 
   Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (1,430 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
     Introduction
     Case Report
     Discussion
     Conclusions
    References
    Article Figures

 Article Access Statistics
    Viewed696    
    Printed43    
    Emailed0    
    PDF Downloaded40    
    Comments [Add]    

Recommend this journal